HEALTHCARE Engineering Alliance Society

 

HEALTHCARE ENGINEERING ALLIANCE SOCIETY MEMBERSHIP APPLICATION

 

*Mandatory information

 

PERSONAL INFORMATION

MALE* ____    FEMALE* _____  DATE OF BIRTH (Day/Month/Year)* ________________

TITLE ___  FIRST NAME* _____________ MIDDLE NAME _______ 

LAST/SURNAME* _________________

HOME ADDRESS* ______________________________

CITY* _____________________ STATE/PROVINCE* _____________________________

ZIP / POSTAL CODE* ______________________  COUNTRY* ____________________________

TELEPHONE* ___________________________

E-MAIL: 1.* ____________________________ 2. ___________________________

SEND MAIL TO: HOME ADDRESS __________________ BUSINESS ADDRESS _________________

 

EDUCATIONAL INFORMATION

ARE YOU A CURRENT STUDENT*?  YES _________     NO  ____________

HIGHEST DEGREE RECEIVED OR CURRENTLY PURSUED*: BACHELOR ________ MASTER ________ DOCTOR _____________ MEDICAL DOCTOR ___________________ OTHERS (SPECIFY) ___________________________

MAJOR/PROGRAM/COURSE OF STUDY* ___________________

COLLEGE/UNIVERSITY* ____________________________

CITY* ______________________  STATE/PROVINCE* ______________________ COUNTRY* _______________________

TIME OF GRADUATION*: MONTH _________________ YEAR  ______________________

 

BUSINESS/PROFESSIONAL INFORMATION (NOT REQUIRED FOR STUDENTS)

TITLE/POSITION* ________________________________

EMPLOYER NAME* ______________________________________

STREET ADDRESS* ______________________________________

CITY* _________________ STATE/PROVINCE* ___________________________

ZIP / POSTAL CODE* ___________________________ COUNTRY* _________________

OFFICE PHONE* ______________________ OFFICE FACSIMILE _____________________

PROFESSIONAL SPECIALTIES* _____________________________________________________________

_____________________________________________________________________________________

 

SERVICE INTERESTS

PLEASE SELECT COMMITTEE(S) YOU ARE INTERESTED IN SERVING FROM OUR COMMITTEES LIST

1. _______________________________________________.

2. _______________________________________________.

3. _______________________________________________.

 

COMPANION MEMBER

1. EACH NEW MEMBER IS REQUIRED TO RECRUIT A NEW COMPANION MEMBER WHO HAS NEVER BEEN A MEMBER OF HEALS.

2. THE COMPANION MEMBER MUST ALSO REGISTER AS A MEMBER.

 

COMPANION MEMBER'S INFORMATION:

TITLE ___   FIRST NAME* _____________ MIDDLE NAME ___________________ 

LAST/SURNAME* _________________

HOME ADDRESS* ______________________________

CITY* _____________________ STATE/PROVINCE* _____________________________

ZIP / POSTAL CODE* ______________________  COUNTRY* ____________________________

TELEPHONE* ___________________________

E-MAIL: 1.* ____________________________ 2. ___________________________